In 2014, the American College of Obstetrics and Gynecology published guidelines for diagnosing failed induction of labor (FIOL) and arrest of dilation (AOD) to prevent cesarean delivery (CD). The objectives of this study were to determine the rate of adherence to these guidelines and to compare the association of guideline adherence with physician CD rates and obstetric/neonatal outcomes.
Retrospective cohort review of singleton primary cesarean deliveries for FIOL and AOD at a single academic institution from 2014 to 2016. Univariate and multivariate analyses were used to compare adherence to the guidelines with physician CD rates and obstetric/neonatal outcomes.
Of the 591 cesarean deliveries in the study, 263 were for failed induction, 328 for AOD and 79% (468/591) were not adherent to the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine (ACOG/SMFM) guidelines. Of the failed inductions, 82% (215/263) and of the AODs 77% (253/328) were not adherent. There was no difference between adherent and non-adherent CDs with regard to maternal characteristics, or obstetric/neonatal outcomes. Duration of oxytocin use after rupture of membranes, dilation at time of CD, and birth weight were statistically higher in adherent CDs. On multivariate linear regression, physician CD rates were inversely correlated with adherence to ACOG/SMFM guidelines (p<0.0001), gestational age (p=0.007), and parity (p=0.003).
Our study shows that physician non-compliance with ACOG guidelines was high. Adherence to these guidelines was associated with lower physician CD rates, without an increase in obstetric or neonatal complications.
Research funding: None declared.
Author contributions: WSM, YA, MTB and TC designed the study. AO and EN built the database, WSM and CE analyzed the database and reviewed each CD and applied guidelines. YA settled any disputes. AA performed statistics. CE, WSM, YA, MTB, TC and AG all wrote and edited the manuscript. All authors have accepted responsibility for the entire content of this manuscript and approved its submission.
Competing interests: Authors state no conflict of interest.
Informed consent: Informed consent was obtained from all individuals included in this study.
Ethical approval: Ethics approval and consent to participate: The research related to human use has been complied with all the relevant national regulations, institutional policies and in accordance the tenets of the Helsinki Declaration, and this study was approved by the Institutional Review Board at our study institution (18-01964).
Location of study: Obstetrics and Gynecology, New York University, New York, NY.
Availability of data: The dataset from this article is not available due to the fact it contains protected health information.
Findings presented at: Society of Maternal Fetal Medicine 2018, Poster presentation, Abstract #832, Dallas, TX, January 29th–February 3rd, 2018.
|Gestational age||Determined based on the last menstrual period, confirmed with or corrected by first- or early second-trimester ultrasonography|
|Body mass index (BMI)|
|Medical and obstetric co-morbidities|
|Prior cesarean delivery|
|Chronic hypertension||Elevated blood pressure (BP) ≥140/90 with first elevation at less than 20 weeks of gestation|
|Gestational hypertension||Elevated BP as above with first elevation at 20 weeks of gestation or greater|
|Preeclampsia||Elevated BP as above with proteinuria of 1+ or more on urinalysis or ≥300 mg over 24 h|
|Pre-gestational diabetes||Diabetes diagnosed before pregnancy or before 20 weeks|
|Gestational diabetes||Diabetes diagnosed during pregnancy based on an abnormal 3 h glucose tolerance test|
|Oligohydramnios||Amniotic fluid index less than 5 cm|
|Intrauterine growth restriction||Estimated fetal weight less than the 10th percentile|
|Other maternal comorbidities||Cancer, rheumatologic disorders, and epilepsy|
|Bishop score at presentation|
|Induction of labor||Categorized based on the provider’s documentation in the admission note and confirmed by review of the history, initial cervical exam, and tocodynamometer findings|
|Induction methods||Prostaglandin, cervical balloon, oxytocin|
|Duration of oxytocin administration|
|Duration of rupture of membranes|
|Use of intrauterine pressure catheter (IUPC)|
|Labor complications||Meconium, chorioamnionitis or any hypertensive disorder that developed during labor|
|Obstetrician at time of delivery|
|Indication for cesarean delivery||Based off indication listed in the operative report|
|Date and time of cesarean delivery|
|Cervical exam at time of delivery|
|Fetal position at time of delivery||Defined as favorable or unfavorable, with favorable positions being any occiput anterior position|
|Category of tracing at time of delivery||Based off documented category of tracing by physician at time of delivery|
If no category of tracing was documented, or if there was a discrepancy within the documentation at time of delivery, the strip was reviewed by two different reviewers (CE and SM)
If there was a disagreement between these two reviewers, a third reviewer (YA) made the final determination
|Cesarean complications||Transfusions, endometritis, wound complications and neonatal injuries|
|Estimated blood loss|
|Neonate disposition||Defined as admission to either the neonatal ICU or regular nursery|
|APGAR scores||At 1 min and 5 min|
1. Hamilton, BE, Martin, JA, Osterman, MJ, Curtin, SC, Matthews, TJ. Births: final data for 2014. Natl Vital Stat Rep 2015;64:1–64.Search in Google Scholar
2. Gregory, KD, Jackson, S, Korst, L, Fridman, M. Cesarean versus vaginal delivery: whose risks? whose benefits?. Am J Perinatol 2012;29:7–18. https://doi.org/10.1055/s-0031-1285829.Search in Google Scholar
3. Hansen, AK, Wisborg, K, Uldbjerg, N, Henriksen, TB. Risk of respiratory morbidity in term infants delivered by elective caesarean section: cohort study. BMJ 2008;336:85–7. https://doi.org/10.1136/bmj.39405.539282.be.Search in Google Scholar
4. Burrows, LJ, Meyn, LA, Weber, AM. Maternal morbidity associated with vaginal versus cesarean delivery. Obstet Gynecol 2004;103:907–12. https://doi.org/10.1097/01.aog.0000124568.71597.ce.Search in Google Scholar
5. Kozhimannil, KB, Law, MR, Virnig, BA. Cesarean delivery rates vary tenfold among US hospitals; reducing variation may address quality and cost issues. Health Aff 2013;32:527–35. https://doi.org/10.1377/hlthaff.2012.1030.Search in Google Scholar
6. Hospital maternity-related procedures and practices statistics. New York state Department of Health. Available from: [Acessed 1 May 2019].Search in Google Scholar
7. McClelland, S, Gorfinkle, N, Arslan, AA, Benedetto-Anzai, MT, Cheon, T, Anzai, Y. Factors associated with cesarean delivery rates: a single-institution experience. Matern Health Neonatol Perinatol 2017;3:8. https://doi.org/10.1186/s40748-017-0047-z.Search in Google Scholar
8. Barber, EL, Lundsberg, LS, Belanger, K, Pettker, CM, Funai, EF, Illuzzi, JL. Indications contributing to the increasing cesarean delivery rate. Obstet Gynecol 2011;118:29–38. https://doi.org/10.1097/aog.0b013e31821e5f65.Search in Google Scholar
9. Caughey, AB, Cahill, AG, Guise, JM, Rouse, DJ. American College of Obstetricans and Gynecologists, Society for Maternal-Fetal Medicine Safe prevention of the primary cesarean delivery. Am J Obstet Gynecol 2014;210:179–93. https://doi.org/10.1016/j.ajog.2014.01.026.Search in Google Scholar
10. Thuillier, C, Roy, S, Peyronnet, V, Quibel, T, Nlandu, A, Rozenberg, P. Impact of recommended changes in labor management for prevention of the primary cesarean delivery. Am J Obstet Gynecol 2018;218:341 e1–9. https://doi.org/10.1016/j.ajog.2017.12.228.Search in Google Scholar
11. Rosenbloom, JI, Stout, MJ, Tuuli, MG, Woolfolk, CL, Lopez, JD, Macones, GA, et al. New labor management guidelines and changes in cesarean delivery patterns. Am J Obstet Gynecol 2017;217:689 e1–8. https://doi.org/10.1016/j.ajog.2017.10.007.Search in Google Scholar
13. Kim, LH, Cheng, YW, Delaney, S, Jelin, AC, Caughey, AB. Is preeclampsia associated with an increased risk of cesarean delivery if labor is induced?. J Matern Fetal Neonatal Med 2010;23:383–8. https://doi.org/10.3109/14767050903168432.Search in Google Scholar
14. Casey, BM, Lucas, MJ, McIntire, DD, Leveno, KJ. Pregnancy outcomes in women with gestational diabetes compared with the general obstetric population. Obstet Gynecol 1997;90:869–73. https://doi.org/10.1016/s0029-7844(97)00542-5.Search in Google Scholar
15. Lomas, J, Enkin, M, Anderson, GM, Hannah, WJ, Vayda, E, Singer, J. Opinion leaders vs audit and feedback to implement practice guidelines. Delivery after previous cesarean section. JAMA 1991;265:2202–7. https://doi.org/10.1001/jama.1991.03460170056033.Search in Google Scholar
16. Clark, SL, Frye, DR, Meyers, JA, Belfort, MA, Dildy, GA, Kofford, S, et al. Reduction in elective delivery at< 39 weeks of gestation: comparative effectiveness of 3 approaches to change and the impact on neonatal intensive care admission and stillbirth. Am J Obstet Gynecol 2010;203:449.e1–6. https://doi.org/10.1016/j.ajog.2010.05.036.Search in Google Scholar
17. Althabe, F, Belizan, JM, Villar, J, Alexander, S, Bergel, E, Ramos, S, et al. Mandatory second opinion to reduce rates of unnecessary caesarean sections in Latin America: a cluster randomised controlled trial. Lancet 2004;363:1934–40. https://doi.org/10.1016/s0140-6736(04)16406-4.Search in Google Scholar
18. Poma, PA. Effect of departmental policies on cesarean delivery rates: a community hospital experience. Obstet Gynecol 1998;91:1013–8. https://doi.org/10.1097/00006250-199806000-00027.Search in Google Scholar
20. Zhang, J, Landy, HJ, Branch, DW, Burkman, R, Haberman, S, Gregory, KD, et al. Contemporary patterns of spontaneous labor with normal neonatal outcomes. Obstet Gynecol 2010;116:1281–7. https://doi.org/10.1097/aog.0b013e3181fdef6e.Search in Google Scholar
© 2020 Walter de Gruyter GmbH, Berlin/Boston